What is the protocol for treating a patient with an active cold sore? Do universal precautions cover the risks involved?
Herpes outbreaks, also known as “cold sores,” are very common. Caused by the herpes simplex virus (HSV), HSV is divided into two categories: oral (type 1, or HSV-1) and genital (type 2, or HSV-2).1 Dental professionals are most concerned with HSV-1, as it affects approximately 80% of the population.2 Patients who present with HSV-1 may experience early symptoms, such as itching, tingling, and burning with an outbreak of vesicles or blisters around the vermillion border of the lips, which break open and become a sore.3 These sores are also commonly known as “fever blisters” and may coincide with being ill, fatigued, stressed, or run down. HSV-1 is contracted through direct contact with active weeping sores, kissing, and sharing of oral objects such as toothbrushes. Cold sores are highly contagious and can be spread easily, especially during the vesicle stage when the virus is most virulent.3 No cure is available at this time, but several products can help ease the discomfort of cold sores. HSV-1 remains a latent infection in the trigeminal ganglion and is recurrent from various triggers such as stress, fatigue, and sunlight.3
HSV-1 should not be confused with aphthous ulcers, which occur intraorally. Aphthous ulcers are generally single lesions without prodromal symptoms, whereas HSV-1 usually exhibits multiple coalescing vesicles. Both HSV-1 and aphthous ulcers are recurrent infections.
HSV-1 exhibits several stages, including the tingle, vesicle, ulcer, scab, and healing. First, a tingle or burning sensation may be felt before a lesion appears. Antiviral creams applied at this time might prevent a breakout. Second, one or multiple fluid-filled vesicles form typically the day after tingling. The vesicle stage is when the highest viral load is present and is most contagious. Third, vesicles may burst and create an ulcer or sore that can be very painful. Fourth, a scab will form over the sore as protection. Lastly, the healing stage occurs approximately 10 days to 14 days from onset.
Prudent infection control procedures should be followed so as not to spread the virus. The use of universal precautions and personal protective equipment such as masks, gloves, and eyewear is enough protection for the clinician. The United States Centers for Disease Control and Prevention (CDC) does not have specific guidance related to treating patients with cold sores. However, CDC guidance has work restrictions for clinicians with active herpes lesions on the hands (herpetic whitlow) to avoid patient contact until the lesions heal.4 However, dental professionals should be careful to avoid spreading the virus around the patient’s face such as into the nose or eyes. Patients who present with cold sores, especially in the vesicle stage, should be advised of the potential risk of spreading the virus to the nose or eyes if oral tissues are manipulated. Many dental practices have policies on treating (or not treating) patients with active cold sores. It is up to each oral health professional to decide when it is safe to treat patients with active cold sores. My professional opinion would be to defer dental treatment until the lesion is in the scab or healing stages.
- Web MD. Herpes Simplex 1 and 2. Available at: webmd.com/genital-herpes/pain-management-herpes#1. Accessed October 12, 2018.
- Holistic Dental Centre. Cold Sore Policy. Available at: holisticdentalcentre.co.uk/pdf/cold-sores-policy.pdf. Accessed on October 13, 2018.
- Ibsen O, Anderson-Phelan J. Oral Pathology for the Dental Hygienist. 7th ed. Amsterdam, Netherlands: Elsevier; 2018.
- Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep. 2003 Dec 19;52(RR-17):1-61.